Provider Demographics
NPI:1467914630
Name:O'BRIEN, TRACEY GLENN (MD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:GLENN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8268 164TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1104
Mailing Address - Country:US
Mailing Address - Phone:203-651-9147
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:475-210-5663
Practice Address - Fax:475-210-4079
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT077052207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine